Fetal cardiac failure resulting from congenital anomalies of the heart

Cardiac abnormalities associated with hydrops fetalis

Cardiovascular abnormalities are associated with hydrops fetalis in 26% of cases reported in the modern era. These include not only structural abnormalities, but also cardiac arrhythmias, failure, tumors, myopathy, infection, inflammation, infarction, and arterial calcification. Cardiac structural abnormalities may be causative or seen only in association with hydrops fetalis. Structural lesions that result in right atrial pressure or volume overload seem to be most commonly associated with hydrops fetalis. Fetal cardiac tumors, cardiomyopathy, myocarditis, myocardial infarction, and arterial calcification probably result in hydrops fetalis by a similar mechanism. Fetal tachyarrhythmia has been shown to result in elevation of atrial pressure and atrial natriuretic peptide. Fetal tachyarrhythmias are the most treatable of cardiac causes of hydrops fetalis. Fetal bradyarrhythmias are less easily treatable and less certainly a causative mechanism of hydrops fetalis.

Clinical and histopathological features of parvovirus B19 infection in the human fetus

OBJECTIVE

To provide a comprehensive description of the clinical and histopathological features associated with parvovirus B19 infection of the human fetus.

SUBJECTS

All cases of parvovirus B19-related fetal death presenting to the John Radcliffe Hospital, Oxford, over a 16 year period. Diagnosis was confirmed retrospectively by non-isotopic in situ hybridization for parvovirus B19 DNA.

RESULTS

The ten cases occurred in two clusters (1979-80 and 1988-89) and presented between 15 and 29 weeks gestation. In at least three cases maternal infection was asymptomatic. Nine fetuses were grossly hydropic at necropsy. Histological features common to all cases included the presence of typical intranuclear inclusions in erythroid precursor cells and evidence of vasculitis within placental villi. Inflammatory changes were also present in the myocardium of four cases, with evidence of subendocardial fibroelastosis in three.

CONCLUSIONS

Histological features of fetal parvovirus B19 infection are similar across a range of gestational ages. The heart failure and hydropic state associated with fetal parvovirus infection may be of multifactorial aetiology, and not due to fetal anaemia alone.

Cardiac abnormalities and nonimmune hydrops fetalis: a coincidental, not causal, relationship

Few conditions associated with nonimmune hydrops fetalis have had a demonstrable causal relationship. Congenital heart disease is often said to be a cause of nonimmune hydrops fetalis and antenatal closure of the foramen ovale is the cardiac abnormality most frequently reported in association with hydrops. In order to examine the role of congenital heart disease in hydrops, and, in particular, that of antenatal closure of the foramen ovale, we reviewed all autopsy cases with hydrops fetalis over an 11 year period and compared cardiac anomalies with those of nonhydropic controls. The incidence of various congenital heart malformations was not significantly different among these groups, suggesting that factors in addition to cardiac anomalies must be considered in the pathogenesis of nonimmune hydrops fetalis.

Fetal hydrops in a newborn with hypoplastic left heart syndrome: tricuspid valve "stopper"

Fetal hydrops in a newborn infant with hypoplastic left heart syndrome led to the discovery of tricuspid stenosis and insufficiency from an unusual malformation of the right venous valve of the embryonic sinus venosus. This unfortunate combination of lesions precluded surgical palliation for the hypoplastic left heart.

Absence of the aortic valve: antenatal and postnatal two-dimensional and Doppler echocardiographic features

Antenatal and postnatal two-dimensional and gated pulsed Doppler echocardiography, beginning at 32 weeks' gestation, were used to evaluate the cardiovascular contribution to nonimmunologic hydrops in a gravida 1, para 0 nineteen year old woman. Antenatal two-dimensional imaging demonstrated a hypoplastic left heart variant of complete common atrioventricular (AV) canal. Antenatal gated pulsed Doppler examination of the fetal thoracoabdominal aorta revealed atypical pandiastolic retrograde flow. Postnatal noninvasive examination at 36 weeks' gestational age was unchanged from the prenatal study. Postmortem examination confirmed the noninvasive anatomic findings and revealed polysplenia. The mechanism of pandiastolic retrograde flow was attributable to "absence of the aortic valve," a previously unreported congenital cardiac anomaly, which resulted in severe antenatal and postnatal aortic regurgitation.

Fetal echocardiography for evaluation of in utero congestive heart failure

Thirteen fetuses with nonimmune hydrops (22 to 39 weeks of gestation) were evaluated with two-dimensional and M-mode echocardiography. Ten fetuses had cardiovascular abnormalities resulting in heart failure, and three had noncardiac causes of hydrops. In three cases, hydrops was caused by supraventricular tachycardia. One of these fetuses responded to cardioversion at birth, another responded to transplacental digoxin therapy, and the third died with atrial flutter and high-grade atrioventricular block before delivery. There were no cases of "idiopathic" hydrops. Our results show that fetal echocardiography is useful in determining cardiac causes of in utero heart failure resulting in hydrops fetalis. The fetal echocardiogram may also be used in monitoring transplacental therapy of heart failure.

Differential diagnosis of hydrops fetalis

Apart from isoimmunization, a number of conditions may present as hydrops fetalis and now account for a large proportion of hydropic infants. A large differential diagnosis must be considered when investigating the hydropic fetus and placenta while in utero, in the neonatal period, and at autopsy. An investigative protocol is proposed.

Premature contraction of the ductus arteriosus: a cause of foetal death

Necropsy findings are presented of two cases of foetal heart failure secondary to premature, in-utero contraction should lead to a redirection of the right heart output either through the pulmonary vascular bed or to the systemic circulation via the foramen ovale. The muscular pulmonary arteries, however, were not dilated, indicating that no excessive pulmonary flow had occurred. The increased volume load on the right heart may have rendered the foramen ovale restrictive, with right-sided heart failures as a consequence. Premature closure of the ductus arteriosus should be considered a cause of foetal or early neonatal death.